Down the rabbit hole: Women’s health in Ireland

Image Credit: Reproductive Health Supplies Coalition

Sophie Finn navigates the murky waters of women’s health in Ireland, examining the system through the lens of both teaching and practice.

Women’s health has a fractured history in Ireland. Although a multitude of issues still exists in the practice of women’s health, particularly sexual health, recent progressive changes have influenced the area. However, the teaching of medicine must also progress to prevent the perpetuation of Ireland's medical mistreatment of women.

The health system in Ireland is wrought with issues, from long waiting lists to a lack of facilities and resources. For certain cohorts such as women and minorities, these issues are exacerbated due to the fact the medicine system as it stands is not designed for them. Modern medicine was primarily created by white men; therefore, the practice best serves that demographic. 

Internationally, there has been a history of mistreatment of women in the medical system. Ireland is no exception to this, and in some situations women’s health has been more neglected in our country, possibly due to the connection between religious institutions and sexual health. Women have experienced horrific mistreatment, from symphysiotomies and the routine institutionalisation of women, to the death of Savita Halappanavar and the CervicalCheck scandal. 

“Medical issues that only affect women are notoriously under researched and underfunded”

Medical issues that only affect women are notoriously under researched and underfunded. Menopause, menstruation and hormonal or fertility issues are prime examples of this. Medical issues that predominantly affect women are also under-resourced, there are only three specialist treatment centres for eating disorders in Ireland. There also seems to be a certain reluctance to quickly resolve issues affecting women, for example the slow removal of the Covid visiting restriction in maternity hospitals. Further, there have been numerous reports of women feeling dismissed or not listened to by doctors when it comes to concerns about their sexual health.

Budget 2022 has attempted to combat the issue, with €47 million dedicated to women’s health. The funding will primarily go towards the Action Plan for Women’s Health 2022. However, reproductive health has also experienced increased funding, in particular the opportunity to avail of free contraception for women between 17-25, funding for the National Maternity Strategy and a commitment to tackle period poverty. 

Although this is positive progress, and recent changes such as repealing the eighth amendment have made headway for women’s reproductive rights, there is still a question of whether the medical system as it stands, the teaching of medicine and the attitude of practitioners are perpetuating problems regarding women’s health in Ireland. As the National Women’s Council of Ireland (NWCI) outlined “the different and distinct health experiences of women and men remains absent from general health policy and service development. It is also the case that many health services and policies remain built around expectations and features of male patients, with associated treatments also often based on male-dominated studies and trials. This approach presents difficulties for women.”

Minister for Health Stephen Donnelly recently published a report commissioned by the Women’s Health Taskforce, which interviewed over 270 women in Ireland in a ‘radical listening’ exercise on their experience of healthcare in Ireland. The results emphasised that although many women experience positive healthcare, there are issues relating to information, respect, and access. This result may be due to sexist discrimination, as the NWCI stated, “many women report difficulties in accessing health services, linked to discriminatory or stereotypical views held by doctors and health care practitioners and poor diagnosis and treatment for the causes of mental health or heart disease.”

“It’s one thing to appear to be liberal without actually taking the step of doing something practical around it”

To gain an insight into the practice of women’s health in Ireland the University Observer spoke to Dr Máire Finn, a General Practitioner (GP) and specialist in women’s health and well-being. “Female health care internationally has always been poor, and Ireland may have been particularly poor due to the other confounding issues around the church and state, religion and all these other issues that compromised women’s health”. Dr Finn believes there is a significant difference between the medical treatment of women and men. The doctor recalls the introduction of the mother and child scheme by former Minister for Health Noël Brown as a significant moment highlighting the contrasting treatment, outlining this was the first-time female health care was prioritised, and the country went into a “tailspin”.

“Sexual health was not sexual health, for the Catholic religion sexuality was about providing children” outlined Dr Finn, who commented that a major factor affecting female health in Ireland is the strong connection between women’s sexual health and the Catholic church. “The biggest issue from a female health point of view, is the fact that church teachings around sexual health dictated how the medical profession reacted to females looking for contraceptive cover. Sex meant babies and nothing more. The idea of sexual health or contraceptives was completely outside the medical professionals thinking up until the 1980s”. The GP clarified that this mode of thinking was not particular to Ireland but prevalent in many religious dominated states.

Dr Finn noted the causes for the “many flaws in the system” are myriad. “Some of them are international, some are due to a patriarchy which is across the world, some of them very much related to the medical profession being traditionally male and white”. The GP observed that members of the medical profession have often come from a “gilded background” and “didn’t believe people of a lower socioeconomic background required proper care or should even request it”. 

The Doctor noted that in recent times Ireland has progressed positively, particularly with the repeal of the eighth amendment, and the introduction of termination of pregnancy (TOP). Dr Finn was the first GP in Clare to provide TOP, this move resulted in her practice being picketed with people dropping wooden crosses at the door.

The GP outlined that although a large percentage of the medical population voted for Repeal, when the legislation was introduced, they weren’t willing to provide the service. “It’s one thing to appear to be liberal without actually taking the step of doing something practical around it” she explains. Although the country as a whole progressed when Repeal was passed, Dr Finn noted that on an individual level there are still many issues. Few GPs provide the service, several counties don’t offer the service at all, and many people in the general population have extremely strong views against TOP, which Dr Finn believes is one of the reasons many doctors do not offer the service. “People kind of think Ireland has done well, but in fact it hasn’t done that well at all”.

Discussing how women’s health services could be improved in Ireland, Dr Finn endorses a more “collaborative” and “holistic” approach. “One of the biggest problems I see in women’s health in Ireland, and possibly globally, is there is a very patriarchal way of looking at women, especially younger women’s sexual health. It’s not looking at it in a holistic way, looking at how to deal with sexuality and pleasure, it's only dealing with contraception, and how to avoid women getting pregnant”. 

She added that the approach doesn’t focus on the effect of hormones, the pill, or long acting reversible contraceptives such as the coil. “The idea is you put a coil into someone for 5 years and she won’t get pregnant, she might be miserable on the coil, but at least she won’t be pregnant. That thinking is wrong, that’s not how we should be approaching it”. Dr Finn outlines that this over emphasis on preventing pregnancy results in a lack of education about overall sexual health, including non-heterosexual sex, pleasure, and practical issues such as barrier methods and STIs. “You have someone put on the pill, but they could end up with chlamydia two weeks later”.

The Doctor contends this approach is due to a lack of training on female sexual health, particularly in GP training. “There isn’t an awful lot of education around it. GPs are the people who deal with contraceptive cover or family planning or other issues but there’s very little training. Any training I’ve had I have had to go and source myself”. Medicine students undertake a general undergraduate degree before specialising in their area of choice. Dr Finn believes the undergraduate teaching on women’s health is not adequate. However, she contends the specialist GP training presents a major issue. The GP training involves a period in an obstetrics and gynaecology unit; however, this is hospital-based medicine, and most female health issues GPs are confronted with are not hospital based.

Courses which teach GP based women’s health are taught by other GPs. However, there is a lack of GPs qualified to train, and GP’s must source the training themselves, which costs time and money. Dr Finn noted it will likely only be sourced if the GP has a particular interest in the area. “Out of 100 GPs, there may only be 10 with an interest, and only 5 experts.” Dr Finn outlined that although this is expected as GPs cannot be experts in everything, the unclear and differing specialities of doctors may be a flaw in the GP system. 

Different parts of the country diverge in their level of expertise in female health due to the varying levels of GP expertise. To receive the best medical advice in the current situation Dr Finn advises people to research and cherry-pick their GP and think of themselves as a customer. However, Dr Finn added this system is not accessible to many, as people with medical cards do not have the privilege to choose which GP to use, and the specialities of doctors are often community knowledge therefore many people won’t have access to the information. To amend the inconsistencies, Dr Finn believes GP’s need to be recognised as sub specialised. However due to the fact General practices are small individual business, the system would likely need to be nationalised to accommodate this.

“there is a very patriarchal way of looking at women, especially younger women’s sexual health. It’s not looking at it in a holistic way, looking at how to deal with sexuality and pleasure, it's only dealing with contraception, and how to avoid women getting pregnant”

Dr Finn concluded “GP and medicine in general has to be more collaborative, there will be some people resistant to that as they view anyone asking questions assume questioning their authority, but that’s not what medicine should be about, it should be about one person having knowledge and another accessing knowledge”. She outlined there is not one best approach to a general medical problem, there are choices and options, and the individual circumstances of a person must be considered, therefore a more collaborative would prevent the recurrence of “gross mistakes made over the decades because the head guy said this is way it should be, and something horrific was done to somebody”. 

To gain a perspective of how women’s health is currently taught in Ireland, the University Observer spoke to a 2020 medical graduate of University College Cork (UCC). The graduate is working in a hospital setting and has a positive view of the teaching of medicine today. 

“I was in College during the Abortion referendum and can remember the mood then. Most Doctors and definitely Obstetricians and those involved in women’s health seemed to be all for it as it represented more independence and freedom for women. I do certainly remember some Consultants and GP's being against it. Religious in some instances but maybe also due to resistance to change.”

They believe there is an adequate emphasis placed on the teaching of women’s health in Ireland. “I think it was in UCC in any case but I'd accept correction. Both Obstetricians/Gynaecologists and GP’s with a special interest in women’s medicine taught us throughout the years. We had specific Obstetrics month long placements in both clinical years. From a medical student perspective I feel we were taught all about all types of contraception and their pros and cons and also about how to access abortion services.”

“You have someone put on the pill, but they could end up with chlamydia two weeks later”

 “I think it is being taught well but I’m sure there’s room for improvement. As a male there’s a big chance I was/am blind to some issues also. In the general (non-maternity / gynaecology) hospitals I certainly remember the attitude towards women's health and sexual health was to defer to / ask for the assistance of our colleagues in the Maternity Hospital. However I do feel that there needs to be a large public health drive towards some sort of equality in sexual health. I feel that as well as female sanitary products, contraception should be either free or a lot cheaper and more accessible. Also there should be a drive towards male contraception.”

The graduate believes the teaching is thorough and does not need to be changed “I haven’t been a doctor for too long and maybe my view will change but as of now I don't think so. Medicine wasn’t my first degree and in comparison to my previous one I felt it was taught very well. It begins with a grounding in theory and slowly moves into clinical placements which are the backbone of learning how to be a doctor. During the clinical placements we would also have lectures to direct our learning. During a month-long Obstetrics and Gynaecology placement for example we would both attend lectures and be required to attend different Obstetrics and Gynaecology departments which would then ground the learning.”

Progress has been made in women’s health in Ireland with important changes such as Repeal implemented, and the introduction of progressed reproductive health changes in Budget 2022. The approach to teaching women’s health today may also have improved in terms of the emphasis on female health. However, it seems a fundamental shift in medical practice must occur to do more than just accommodate women in a system designed for men. Issues regarding outdated approaches to sexual health, and barriers to access for women’s reproductive health must be removed rapidly. Further there is clearly a need for specialist training, particularly for GPs, in women’s health, or a modernisation of the GP system to facilitate equal access for all women to equal and quality healthcare at a local level.